Authorization for Release of Information

Authorization for Release of Information

All Clients

Client Information

Today's Date(Required)
Name(Required)
Name(Required)
Date of Birth(Required)
Address(Required)

Release of Information

Release Information to(Required)
Collect Information from(Required)
Discuss Information with(Required)
This Release of Information is reguarding(Required)
Your Rights with Respect to this Authorization Right to inspect or copy the health information to be used or disclosed – I understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed by this release form. Right to receive a copy of this release–I understand that if I agree to sign this authorization, which I am not required to do, I will be provided with a signed copy of this form upon request. Right to withdraw this authorization–I understand written notification is necessary to cancel this authorization. I am aware that my withdrawal will not be effective as to uses and/or disclosures of my health information that the entity(s) listed above have already made in reference to this authorization. Right to refuse to sign this authorization–I understand that I am under no obligation to sign this form and that the entity(s) listed above may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits based on my decision to sign this authorization Expiration date–This authorization is good for 1 year from the dated signed. I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes.
By signing this form, I hereby authorize ST CROIX THERAPY, INC. (742 Sterbenz Dr Hudson, WI 54016) to Obtain and/or Release information to the entities/person(s) listed.

Responsible Party Information (Client or Parent/Guardian)

Name(Required)
Name(Required)
Consent to email all reports/records to the email address listed above.(Required)